DEFINITIONS OF THE APPROPRIATENESS CRITERIA FOR THE USE OF PET

The use of PET for clinical indications can be considered appropriate, potentially appropriate, possibly appropriate or inappropriate. The appropriateness criteria for the usefulness of PET are defined as follows:

Appropriate (all the conditions below must be met)

• There is evidence of improved diagnostic performance (higher sensitivity and specificity) compared with other current techniques.
• The information derived from the PET scan influences clinical practice.
• The information derived from the PET scan has a plausible impact on the patient’s outcome, either through adoption of more effective therapeutic strategies or through non-adoption of ineffective or harmful practices.

Potentially appropriate (potentially useful)

• There is evidence of improved diagnostic performance (greater sensitivity and specificity) compared with other current techniques, but evidence of an impact on treatment and outcome is lacking.

Possibly appropriate (appropriateness not yet documented)

• There is insufficient evidence for assessment, although there is a strong rationale for clinical benefit from PET.

Inappropriate

• Improved accuracy of tumor staging will not alter management, or the performance of PET is poorer than that of other current techniques.

DEFINITIONS OF INDICATIONS FOR PET SCANNING

Seven different indications for PET scanning are considered here: diagnosis, staging, response evaluation, restaging, suspected recurrence, followup and radiotherapy (RT) planning. They are defined as follows:

1. Diagnosis: 

• Characterization of mass lesion: indication of whether a mass lesion is benign or malignant
• PET guided biopsy: assistance in guiding biopsy to the region of a tumor with the highest metabolic activity, identified on the PET scan by the area(s) of highest FDG uptake
• Detection of occult primary cancer (cancer of unknown primary site)
• Raised tumor markers: determination of the presence of cancer
• Metastasis: determination of the primary site when metastases have been detected.

2. Staging:

• Assessment of the extent of disease prior to initiation of treatment.

3. Response Evaluation:

• Assessment of treatment response during or after therapy.

4. Restaging:

• Assessment of the extent of disease following initial therapy or when recurrence has been confirmed.

5. Suspected Recurrence: 

• Assessment of the presence of cancer following clinical and/or biochemical suspicion of recurrence.

6. Follow-up:

• Surveillance in the absence of clinical evidence of recurrence.

7. Radiation Therapy (RT) Planning:

• Aid in the placement of radiation fields (this assumes that there has been a decision to use RT).

The 21 Cancers where PET CT is useful in any of the above mentioned appropriateness criteria are as follows : 

(1) Non-small cell lung cancer (NSCLC) 

(2) Small cell lung cancer (SCLC) 

(3) Lymphoma 

(4) Breast cancer 

(5) Melanoma 

(6) Ovarian cancer 

(7) Cancer of the uterus and cervix 

(8) Head and neck cancers 

(9) Kidney cancer 

(10) Germinal tumours 

(11) Cancer of unknown primary (CUP) 

(12) Colorectal cancer 

(13) Gastric carcinoma 

(14) Sarcomas (soft tissue and bone) 

(15) Primary tumours of the central nervous system 

(16) Nasopharyngeal carcinomas 

(17) Gastrointestinal stromal tumours (GISTs) 

(18) Pancreatic adenocarcinoma 

(19) Cholangio- and gallbladder carcinomas 

(20) Oesophageal cancer 

(21) Thyroid cancer. 

Age Adjusted Incidence Rates (AAR) per 100,000 persons of leading cancer sites in Thiruvananthapuram Taluk (2011) as per the published annual report of Regional Cancer Centre thiruvananthapuram's, Population Bases cancer Registry for the thiruvananthapuram Taluk, Kerala is as follows: 

The Age wise incidence of Cancer for each cancer type in male and Female at Regional Cancer Centre thiruvananthapuram, as per its annual report for the year 2012-13 is as follows: 

The annual statistics report of Regional Cancer Centre Thiruvananthapuram has published the referral pattern of patients presenting at the RCC Thiruvananthapuram for 2012-13, as mentioned below: 

 

The below mentioned details specify the presentation of cases in socio-economic category and its divisions and in which clinics these cases presented in the year 2012-13 at Regional Cancer centre thiruvananthapuram, kerala: 

To hypothetically assess the requirement of PET CT in the sate of kerala, using the above statistics which is the most authentic and published by the Regional cancer centre for the year 2012-13, which is also recent, the following inferences can be assumed with great accuracy:

• The number of new cases in RCC per year is approximately 15000.
• The number of cases on follow up in RCC is approximately 193941.
• The total number of cases seen per annum in RCC is 200000 per annum approximately.
• Approximate thumb rule requirement of PET CT imaging in cancer care falls in the region of 50% of all cancer patients. Assuming that 15000 are new patients and about 30% are post treated patients in remission not requiring PET CT at all and about 20% of the followup patients are cured or belong to a group where PET CT may not be usefull, and also assuming the fact that the, out of the remaining 100000 more than 80% have completed their course with no complications and would not require a PET CT for immediate needs of evaluation. The number of patients requiring PET CT in RCC alone would be a minimum of 7500 (New) + 20000 (on Follow up) per annum = 27500 PET CT scans if one scan per year is the requirement per patient, which in general is 2 scans. 
• Assuming a 50% absolute number of the said 27500 which is equal to 13750 on clinical requirement on a absolute nature, which in general is the global trend, and assuming 5 days of PET CT function a week, for 12 months which will give 240 working days and assuming 10 scans can be done in one day on one machine - since FDG has to be flown in, to perform 13750 scans the centre would require 6 PET CT's. 

The minimum basis requirement for handling standardized, cancer care, as is practiced across the globe and in the metros like Mumbai, Delhi, Chennai, Calcutta, Banglore, Hydrabad ect will require 5 PET CT machines in Trivandrum. 

The full indications of PET CT imaging are now available at IAEA Human Health Campus.       

DDNMRC PET Scans at Trivandrum has started functioning since June 2014 at Trivandrum and the following pet Scans are available on a daily basis : 

• 18F FDG Whole Body PET CT : Rs 20500 (RCC Patients) and Rs 22500 (others)
• 68 Ga PSMA PET CT - for Prostate Cancer - Rs 15000/- (daily) from (17th March 2015)
• 68 Ga DOTA TOC/ NOC/ TATE PET CT  for Neuro endocrine Tumors - Rs 22500/- (daily)
• 68 Ga DOTA RGD PET CT Vascular neo genesis (Tumor Viability) - Rs 20500 /- 
• 68 Ga DOTA UBI PET CT for Infection - Rs 10000/- 

For appointments contact : +918592089994 or mail santosh.anthony@molecularglobal.com